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WELL PERMIT APPLICATION FORM <br />HE CIE NVIRONM NTALo EA LTCOUNTY <br />DO PARTMENT (EHD) <br />DEC 3 0 2003 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />SITE <br />MITIGATION <br />UNIT Ili <br />ENVIRONMENT HEALTH NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application Is fiereby made t� 0044oaquin County for a permit to construct and/or install the wcrk described. This application is made in compliance will, San <br />Joaquin County Developmen3 1e, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />t' Assessor's <br />WELL Location 4--I)o m a p ill j V .� Cross Street 11d,'Yya'yl ffl,P City' ('( Zip Parcel# <br />/�fg jj))nn /i ' 6O <br />PROPERTY Owner .� L�� GI�AVI;t`PL•CL Address �C'C'� lP�f I.�'-?�[�t�y City t Zip S � Phon n�� <br />A r ,� ` _ <br />C-57 Contractor Gi G�+�' Ad/dress f 5 i ��Gti�l/L/61 CiW54-J[ 41k4�ZIP !I Lic�Phone# �eY �ODIp <br />Consultant /Sub Cntr /�l y'�7'/( �'/ ��f'f%/Address �G`�L�� k CityS Li727 Phone#Z6)2)�, % <br />T - <br />GIS Coordinates: X Y Township Range Section_ <br />WORK TO BE PERFORMED-. <br />JEW WELL /$QRLNG CPT, GEOPROBE, HYDRO UNCH, HAND -AUGER, OTHER') DESTRUCTION (choose type below) <br />,SOIL BORING # 0 OVER -BORE <br />0 WELL #_ 0 PRESSURE GROUT <br />'Other: _ Grout Specifications: <br />COMMENTS <br />TYPE OF WELL INSTALLATION TYPE <br />0 MONITORING 0 HOLLOW STEM <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN <br />0 VAPOR 0 MUD ROTARY <br />0 AIR SPARGE / Ozone *"PUSH POINT <br />SOIL BORING 0 HAND AUGER <br />0 OTHER:__ f1 OTHER <br />P'l ^ l n /7 <br />*C <br />0 <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 2ii MULTIPLE CASINGS? 0 MULTI-LEVEL? 0 WELL CASING DIA: <br />CASING THICKNESSlUjf� // TYPE OF CASING: 0 STEEL 0 FVC 0 OTHER: <br />DEPTH OF GROUT SEAL Z+1 /7`-)P— TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br />GROUT SEAL PUMPED: 0 Yes IjAo (NOTE: MAXIMUM FREE -PALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: u� �ilr/(Cy �/47� 17- 16-11L -/1,10 _ <br />APPROX. BORING DEPTH 46 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CYNDUCTOR CAS <br />i. _XZ., <br />list specifications here): <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinances, Rules and Regulations, and all applicable California State Laws. <br />Signed <br />Print <br />SITE MAP IN UNIT IV FILE, AD <br />WORK PLAN DATED: Z <br />Title/Company (-- <br />DEPARTMENT USE ONLY <br />Application Accepted By Date Issued (zl, `� Area 6u <br />Grout Inspection By (,� oi, Date Final Inspection By !1 (/(i �n.�G.� Date <br />Destruction Inspection By Date <br />COMMENTS / CONDMONS: <br />ACCOUNTING ONLY: AID#5 S <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PE -RR IT7SERVICE R QUEST # <br />INVOICE <br />35� c*�9-C <br />` <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 8/29/02 <br />it <br />C5' <br />